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Certified Nurse MidwifeA certified nurse midwife in South Dakota has a nursing degree, is considered a primary care provider and is licensed by the Board of Nursing. A CNM generally works in a hospital setting, but can attend home births with a waiver from the board.

Certified Professional MidwifeA certified professional midwife is licensed by the North American Registry of Midwives. To be registered with the group, CPMs must train for two to four years and attend a certain number of births with a certified preceptor. CPMs generally work in homes or birth centers.

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Advocates for non-nurse midwives have spent almost two decades asking lawmakers in the state for recognition.

In response, professional medical associations tell legislators that midwives without traditional medical training are not qualified to attend births.

At least 13 states have extended legal protections to certified midwives since the first South Dakota bill in 1994, bringing to 27 the number of states in which CPMs can practice legally. Only Massachusetts and Illinois have been lobbied by midwife supporters for so long with so little success.

This year’s bill, which would have allowed non-nurse midwives to train in the state under a licensed nurse midwife, died 10-3 in a House committee Thursday.

Home births, midwifery and unmedicated childbirth have become more common, with many women choosing to forgo obstetricians for midwives, eschewing medications and interventions.

The trend slowly has gained traction in South Dakota. The medical community championed a 2008 change in the law that allowed nurse midwives with a nursing board waiver to attend home births.

In 2011, lawmakers cleared the way for birth centers through another Department of Health proposal.

“Both of these bills have expanded options for South Dakota families to have births at home with licensed, qualified providers, or in an alternative home-like environment such as a birth center,” Doneen Hollingsworth, state Health Department secretary, said last week. “These laws need to be given the chance to work.”

With only 223 elective home births in the state the past six years, she said, demand doesn’t justify further expansion.

For Debbie Pease of Birth Matters South Dakota, the issue is not the measure of demand, it’s respect for the families who want options. Those who see birth as a natural, non-medical event want the same right to go around the medical community and use a non-nurse midwife that women in 26 others states and most of the developed world already have.

“It frustrates me that some people think they know what’s best and that we’re crazy if we disagree,” said Pease, a mother of eight who worked with a midwife for her last four children.

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Lobbying legislatures for licensure

Pease’s interest group, South Dakota Birth Matters, has national backing from a group based in Wisconsin called The Big Push for Midwives.

That organization was founded in 2007 to help advocates press for licensure in individual state legislatures.

Katie Prown, a doctor and spokeswoman for the Big Push for Midwives, said more people every year are willing to see midwives and home births as normal, as opposed to fringe methods of delivery.

She points to statistics from the Centers for Disease Control and Prevention, which showed a 29 percent increase in home births from 2004 to 2009.

That advocates have tried and failed to earn support for licensure for 19 years makes South Dakota an outlier, she said.

“That’s not common at all,” Prown said. “The average is five years. In Wisconsin, we did it in one session.”

The difference is not the strength of South Dakota’s conservative streak, Prown said, noting that legislators in more politically liberal states such as Massachusetts and Illinois also have rejected licensure for more than a decade.

“The difference is in the medical and hospital lobbies. Both of those are unusually powerful in South Dakota,” Prown said.

The U.S. and Canada are the only developed nations where non-nurse midwives are seen as inexperienced by doctors and hospitals, Prown said.

Midwifing foes say more training needed

The professional medical community came out against House Bill 1095 on Thursday. Hollingsworth was among the opponents.

She was joined by lobbyists for Avera, Sanford Health, the South Dakota Board of Nursing, the South Dakota Association of Health Care Organizations and the South Dakota State Medical Association and the South Dakota Nursing Association.

The medical groups have concerns about training for certified professional midwives and say that modern medicine has made births safer. Lack of training among non-nurse midwives is the prime argument against licensure, she said, and has been since 1994, when the first midwife proposal appeared.

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Some measures have asked for registration, others for licensure. Some have referred to “direct-entry” midwives, others to “independent practitioners” or certified professional midwives.

“All of these bills have had one thing in common,” Hollingsworth told the committee. “They compromise public health and safety by lowering the standard of care for pregnancy and delivery in South Dakota.”

Dave Hewitt, director of the Association of Health Care Organizations, said certified professional midwife programs vary widely, and lack of standards is an issue.

“The people who are trying to become a CPM need no more than a GED or a high school diploma to start training,” Hewitt said after the hearing. “In our minds, that doesn’t provide the amount of academic training necessary to insure a high standard of care.”

Hewitt said he “can’t imagine” a scenario under which his group would support non-nurse midwives. Hospitals are the safest place to have a baby, he said.

“The birthing process is portrayed (by midwife supporters) as a natural event, but in fact, it is a medical event,” Hewitt said. “Things can happen at a moment’s notice.”

Medical groups noted the availability of home births through certified nurse midwives made possible by recent legislation. Hollingsworth pointed out that four certified nurse midwives performed out-of-hospital births last year in South Dakota.

“Do we need to expand access to midwives in South Dakota? Yes. But they need to be trained and licensed,” she said.

Considerable training, advocate says

Ida Durragh, an Arkansas midwife who leads the testing department of the North American Registry of Midwives, scoffs at the notion that training is lacking for certified professional midwives.

Durragh testified by phone during the hearing for HB1095.

To be recognized by her organization, she said, a certified professional midwife must pass a series of written and hands-on tests covering more than 800 topics including pre- and post-natal care and newborn care.

To be licensed by NARM, she said, an apprentice spends at least two years with a certified professional midwife. Apprentices must take part in 10 births as an observer, assist during 20 births and attend 25 births under the supervision of a trainer before they can earn a license.

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The vast majority of those births happen in homes and birth centers, she said, making certified professional midwives experts in home birth.

Durragh argues that the hands-on and remote learning championed by certified professional midwife schools mirrors many modern programs at traditional colleges.

“They keep saying ‘get educated, get educated.’ Well, they are educated,” Durragh said. “(Opponents) get it in their heads that we only have a high school education and they don’t seem to listen to what’s being said.”

Training is an issue for certified nurse midwives, too, Durragh said, notably that they don’t have experience with out-of-hospital births.

“Certified nurse midwives are not trained in home births,” Durragh said. “Nationally, very few CNMs do home births. If you want a home birth, you go to a CPM.”

A question of C-sections, a matter of costs

A certified nurse midwife in Sioux Falls attends home births, thanks to 2008 legislation. Her name is Debbie Hayden-Miller, and she runs Laughing Waters Midwifery in Sioux Falls.

Hayden-Miller started as a nurse then went back to school to become a certified nurse midwife. After a few months working in a hospital setting, she decided the environment was not right for her.

The cesarean section rates can spook expectant mothers concerned about being pressured into having one unnecessarily. The rate for c-sections at Sanford USD Medical Center in Sioux Falls is 29 percent. At Avera McKennan Hospital in Sioux Falls, the rate is 27 percent.

“There are too many interventions happening in hospitals,” Hayden-Miller said. “There are women out there who don’t want to face the possibility of a 1-in-3 chance for a c-section.”

Hayden-Miller’s practice has grown through word-of-mouth, she said, and her schedule is filled through March.

“Since December especially, things have really taken off,” Hayden-Miller said.

Cost has something to do with that, she said. A hospital birth without interventions costs $8,000 to $9,000. Her starting price point is $3,500 for the birth and the pre- and post-natal care, with discounts for early payment.

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No insurance company has accepted a claim yet, though Hayden-Miller submits them.

Hayden-Miller said he hasn’t had to transfer any of her clients to a hospital for an emergency complication thus far.

“If you’ve done a really good job with prenatal care, you’re not likely to have those. You want to transfer them before it becomes an emergency,” she said.

Different paths in home, hospital births

Terry Engelmann, a certified nurse midwife who practices at Sanford Health in Sioux Falls, doesn’t have an issue with home births. Studies have shown that planned home births for normal pregnancies are not unsafe.

“If you’re well-educated, a home birth is just as safe as a hospital birth,” Engelmann said.

Sanford has four full-time nurse midwives on staff in Sioux Falls. Avera has two.

Engelmann has seen the number of women interested in natural birth increase in recent years as well. She teaches a class called HypnoBirthing to help women who choose to go without medication manage and channel labor pain.

“If they choose not to have drugs or epidurals, we are there to help,” she said.

Laretta McPeek, a patient of Engelmann, wants a low- or no-intervention birth for her first baby, a daughter due in about three weeks. She’s taking the HypnoBirthing class in an effort to avoid drugs.

“One issue that I have is that with an epidural you lose control over your body,” McPeek said. “The doctor can tell you to push, but you can’t really feel what’s going on. I want to know what’s going on, and I want to be in control.”

McPeek has felt that way for a long time, she said, but she wasn’t comfortable with a home birth. She was pleased to learn that Sanford had options for her.

“I’m glad they have it at the hospital, just in case something would happen,” she said.Engelmann sees that as a benefit, too. “If we have a concern, we’re right there,” she said.

A hospital birth was never an acceptable option for Chandelle Brink, a mother of five from Box Elder who long has supported South Dakota Birth Matters.

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Brink and her husband lived in Missouri when she got pregnant with her first child. They saw doctors and told them that they wanted as little intervention as possible.

“They really weren’t willing to give us the care that we wanted,” Brink said. “They basically said, ‘We’ll just have to do what we do.’ That’s why we went with a midwife.”When the Brinks moved to South Dakota, they were shocked to find they couldn’t get one to attend a home birth.

“There was nobody even working underground,” Brink said. “We were willing to go that route, but there was no one to take us there,” Brink said.

Brink delivered her last two children in her home, without an attendant.

“If it’s taken this long already, it’s probably something that won’t be available until my daughters are ready to have kids,” Brink said of licensing. “It’s disgusting.”

Hollingsworth sees the matter differently. Medical professionals are and should be held to high standards, she said, and the certified professional midwife model does not fit the mold or meet those standards.

“The apprenticeship model of (medical) education is not something that is accepted,” she said. “If we give a license from the state of South Dakota, it means we’re telling the public that we think this is safe.”